As we move into the summer season, we are delighted to share with you our most recent round of new grantees and highlight the exciting work they will be conducting in order to improve care for older adults. The John A. Hartford Foundation Board of Trustees has approved $1.67 million to support these projects, which span important topics including the flow of patient information post-hospitalization, the integration of clinical care with social supports for frail older adults, dementia care, and planning for the last phase of life.

These grants build on partnerships with outstanding organizations and individuals who are helping advance our three programmatic areas: creating age-friendly health systems, supporting family caregivers, and improving serious illness and end-of-life care. Each grant will play an important role in moving evidence about good care for older adults into practice. And each project will especially help those older people who have multiple chronic conditions and complex needs.

Understanding Information Continuity and its Impact on Care for Older Adults

Hospitalized older adults with complex conditions are particularly vulnerable to harm as they transition to post-acute care in nursing homes, often referred to as skilled nursing facilities (SNFs). For example, when an older patient with a hip fracture goes to a SNF for rehabilitation, her care can be terribly compromised if information about other conditions, medications, or goals of care are not transferred in a timely, complete, and usable way. Electronic health records have been with us for some time now and should facilitate easier and more accurate information flow, but we still have unanswered questions about the impact and best use of health information technology for information and care continuity for older adults. Stories abound related to poor information exchange.

With a two-year $898,426 grant, a team led by Dr. Ashish Jha of Harvard University with Dr. Julia Adler-Milstein from the University of Michigan will aim to improve care continuity for older adults through developing a better understanding of how information continuity affects patients as they transition from hospital to SNFs. The team will use qualitative case studies, collect new data through a national survey, and use available Medicare data to examine information continuity processes and practices of high and low performing hospital-SNF pairs. Outcomes such as rates of SNF complications, mortality, and preventable hospital readmissions and emergency department visits will be examined, in addition to relevant organizational and policy factors. Using this evidence, the team will create a comprehensive assessment of what constitutes effective information continuity and use that tool to drive improvements in the quality and safety of care transitions for older adults.

PACE 2.0 - Adapting and Disseminating PACE to Serve High-Need Populations

Programs of All-Inclusive Care of the Elderly (PACE) allow low income, frail, older adults with high needs to age at home in the community, rather than be placed in a nursing home. PACE is a comprehensive, cost-effective, community-based care model that has been proven to be effective in meeting the needs of this population.

The model’s success lies in its integration of preventive, primary, and acute care with the incredibly important social supports and services that frail older adults need. Currently, 122 PACE organizations in 31 states serve approximately 40,000 individuals, 90 percent of whom are low-income older adults, eligible for both Medicare and Medicaid.

We are delighted to be partnering with West Health on this two-year $397,792 grant to the National PACE Association to expand access to PACE to 200,000 older individuals. The initiative will build on the recent enactment of the federal PACE Innovation Act, which allows for PACE to serve a wider range of high-need adults. The project will identify new subpopulations the PACE model could serve such as Veterans and the disabled, develop strategies for scale and spread to achieve a five-fold increase in PACE services, and promote implementation of those spread and scale strategies.

Dissemination of a Comprehensive Dementia Care Program that Focuses on Patients and Caregivers Planning Grant

Another new grant project also focuses on spreading a model of care, one that could benefit the more than 5.4 million Americans and their family caregivers who live with the devastating effects of Alzheimer’s disease and other forms of dementia. The UCLA Alzheimer’s and Dementia Care program is a comprehensive co-management program that utilizes nurses as Dementia Care Managers in primary care clinics to help patients and families who are grappling with the disease and its ramifications. Initial evaluation findings provide evidence that this care program improves quality, results in better clinical outcomes for patients and caregivers, and reduces Medicare costs.

The Foundation’s one-year planning grant of $298,887, led by Dr. David Reuben of University of California, Los Angeles, in partnership with the Education Development Center. The grant will develop resources, partnerships, and a strategy for the planned spread of this Dementia Care program across health systems. The goal is to plan dissemination to other institutions through the convening of stakeholders, the creation of an online training course for nursing Dementia Care Managers, and the development of an implementation plan.

Documentary Treatment of “The Best Years: A Film about the Last Phase of Life”

Finally, a $75,000 seven-month grant to Fordham University will support the initial development phase, or treatment, of a national television documentary about the planning and decisions that should be made by individuals and their families in order to prepare for the last phase of life. Planning early in life is critically important, especially for those individuals who ultimately face a diagnosis of serious illness or who develop complex conditions. 

Television continues to have profound and wide-ranging impact on American society and culture and the team’s aim is to create a landmark production that can accelerate the nation’s dialogue about end-of-life issues. The film will explore real-life stories of people dealing with some of the biggest and most important decisions of their lives. It will include discussions about topics such as: talking about and documenting preferences and choices for care; undertaking financial planning; making living arrangements; and identifying caregivers.

The John A. Hartford Foundation is proud to be supporting each of these grant projects that will help us create age-friendly health systems, support family caregivers, and improve care for people with serious illness or at the end of life.